Transforming Hypertension Management in Nigeria

项目 摘要 升高 和 基于 非常 血压（BP）是全球心血管疾病发病率的主要可改变风险因素 mortality.在撒哈拉以南非洲人口最多的国家尼日利亚， 在成人（> 40岁）中，BP阈值> 140/90 mmHg估计为45%。1尽管如此 高负担、高血压知晓率（14 - 30%）、治疗率（<20%）和控制率（9%）非常低， S 尼日利亚。2 2018年对119项试验（n = 55，641名参与者）进行的系统评价，评价实施策略 提高血压控制表明，多层次的团队为基础的护理与非医生的卫生工作者 降压药物滴定是降低收缩压的最有效方法（-7.1 mmHg [95%]）。 CI：-8.9，-5.2]，10项试验）。3降低收缩压最有效的以患者为中心的干预措施是健康 指导（-3.9 mmHg [95% CI：-5.4，-2.3]，38项试验）和家庭BP监测（-2.7 mmHg [95% CI：-3.6，-1.7]， 26项试验）。重要的是，本系统性综述中<20%的研究来自低收入和中等收入人群。 这些国家中没有一个来自撒哈拉以南非洲。 将这些发现转化为常规临床实践需要系统来跟踪患者， 审查，算法，医生将控制权交给非医生，非医生将控制权交给和交给 支持病人，就像整个撒哈拉以南非洲的艾滋病护理一样。我们的试点数据（n = 60） 来自尼日利亚阿布贾的研究已经证明了在1个月时降低收缩压的可行性和短期疗效 社区卫生工作者主导的护理（-10.5 mmHg [95% CI：-15.4，-5.5]）和家庭BP监测（-7.3 mmHg [95% CI：-11.7，-2.8]）。 在本提案中，我们将利用实施科学方法，包括覆盖有效性 采用实施维护（RE-AIM）框架，以适应，实施和评估证据- 一种基于基础的多层次干预，包括：（1）系统级高血压计划，改编自Kaiser 北方加州在联邦首都直辖区的公共初级卫生保健机构的模式 [阿布贾]，尼日利亚，和（2）患者水平的健康指导与家庭BP监测的样本中的高风险 不受控制的高血压患者。我们会研究这些适应化措施的成效和实施情况， 通过中断的时间序列设计，对高血压治疗和控制率进行干预， 以患者为中心的结果。我们 作为 还将使用RE-AIM框架评估实施结果， 以及两种干预措施在系统和患者层面的可接受性和成本。该提案直接解决了NHLBI战略愿景中的关键挑战#11："多学科， 需要建立多国伙伴关系，以制定有效和可持续的战略， 发展中国家的HLBS疾病，考虑到HLBS高度可变的当地流行病学 疾病，需要新的方法来减少疾病负担，以及实施的挑战。4

PROJECT ABSTRACT Elevated and based very blood pressure (BP) is a leading modifiable risk factor f or global cardiovascular disease morbidity mortality. In Nigeria, the most populou country in sub-Saharan Africa, the prevalence of hypertension on a BP threshold >140/90 mmHg in adults (>40 years) has been estimated to be 45%. 1 Despite this high burden, hypertension awareness (14-30%), treatment (<20%), and control (9%) rates are very low in s Nigeria. 2 A 2018 systematic review of 119 trials (n=55,641 participants) evaluating implementation strategies for improving BP control demonstrated that multi-level team-based care with non-physician health worker titration of BP lowering medicines was the most effective approach for lowering systolic BP (-7.1 mmHg [95% CI: -8.9, -5.2], 10 trials).3 The most effective patient-centered interventions for lowering systolic BP were health coaching (-3.9 mmHg [95% CI: -5.4, -2.3], 38 trials) and home BP monitoring (-2.7 mmHg [95% CI: -3.6, -1.7], 26 trials). Importantly, <20% of the studies in this systematic review were from low- and middle-income countries, and none were from sub-Saharan Africa. Translating these findings into routine clinical practice requires systems to track patients, performance review, algorithms, physicians to cede control to non-physicians, and non-physicians to cede control to and to support patients, much like how HIV care is structured throughout sub-Saharan Africa. Our pilot data (n=60) from Abuja, Nigeria already demonstrate feasibility and short-term efficacy in lowering systolic BP at 1 month with community health worker-led care (-10.5 mmHg [95% CI: -15.4, -5.5]) and home BP monitoring (-7.3 mmHg [95% CI: -11.7, -2.8]) compared with usual care. In this proposal, we will utilize implementation science methodologies including the Reach Effectiveness Adoption Implementation Maintenance (RE-AIM) framework to adapt, implement, and evaluate an evidence- based, multi-level intervention that includes: (1) system-level hypertension program adapted from Kaiser Permanente Northern California's model in public, primary health care facilities in Federal Capital Territory [Abuja], Nigeria, and (2) patient-level health coaching with home BP monitoring in a sample of high-risk patients with uncontrolled hypertension. We will study the effectiveness and implementation of these adapted interventions through an interrupted time series design on hypertension treatment and control rates, as well as patient-centered outcomes. We as will also evaluate the implementation outcomes using the RE-AIM framework, well as acceptability and cost, at system and patient levels for both interventions.This proposal directly addresses critical challenge #11 of the NHLBI's Strategic Vision: “Multidisciplinary, multinational partnerships are needed to develop effective and sustainable strategies for combating chronic HLBS disorders in developing nations, which take into account the highly variable local epidemiology of HLBS disorders, the need for novel approaches to reducing disease burden, and the challenges of implementation.”4